Doctor changed treatment after pre-auth

[EFIM D]

My doctor received pre-auth for a certain kind of radiation therapy for my post-op breast cancer but then changed it to a different kind without notifying me. My health care insurance eventually denied the claim as medically unnecessary (better options exist). Two internal appeals were not successful. If an external appeal will not be in my favor what else can I do in this situation? What sort of leverage do I have against the hospital/doctor (both the doctor and hospital are in-network)?

 

[Yagents]

My doctor received pre-auth for a certain kind of radiation therapy for my post-op breast cancer but then changed it to a different kind without notifying me. My health care insurance eventually denied the claim as medically unnecessary (better options exist). Two internal appeals were not successful. If an external appeal will not be in my favor what else can I do in this situation? What sort of leverage do I have against the hospital/doctor (both the doctor and hospital are in-network)?

Your doctor knows pre auth is required for all these types of treatments.

The doctor changed course for some medical reasoning.

That doctor is your best resource and should be compelled to help fight for you, and build a case why the pivot was necessary.

If dr has not helped, or offered limited help, that is best place to start as they are only one that can justify it for you.

 

[leevena]

Yagents is correct.

 

[EFIM D]

Thank you for the answer.

The hospital is filing an external appeal. They say if it does not succeed they will try to get money for the original treatment from the insurance company and the difference if any will be forgiven. Sounds too good but it seems I have no other choice but wait.